The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food?
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The Perils of Ignoring History: Big Tobacco
Played Dirty and Millions Died. How
Similar Is Big Food?
K E L LY D . B R O W N E L L a n d K E N N E T H E . WA R N E R
Yale University; University of Michigan
Context: In 1954 the tobacco industry paid to publish the “Frank Statement to
Cigarette Smokers” in hundreds of U.S. newspapers. It stated that the public’s
health was the industry’s concern above all others and promised a variety of
good-faith changes. What followed were decades of deceit and actions that cost
millions of lives. In the hope that the food history will be written differently,
this article both highlights important lessons that can be learned from the
tobacco experience and recommends actions for the food industry.
Methods: A review and analysis of empirical and historical evidence pertaining
to tobacco and food industry practices, messages, and strategies to influence
public opinion, legislation and regulation, litigation, and the conduct of science.
Findings: The tobacco industry had a playbook, a script, that emphasized
personal responsibility, paying scientists who delivered research that instilled
doubt, criticizing the “junk” science that found harms associated with smoking,
making self-regulatory pledges, lobbying with massive resources to stifle gov-
ernment action, introducing “safer” products, and simultaneously manipulating
and denying both the addictive nature of their products and their marketing to
children. The script of the food industry is both similar to and different from
the tobacco industry script.
Conclusions: Food is obviously different from tobacco, and the food industry
differs from tobacco companies in important ways, but there also are significant
similarities in the actions that these industries have taken in response to concern
that their products cause harm. Because obesity is now a major global problem,
Address correspondence to: Kelly D. Brownell, Rudd Center for Food Policy and
Obesity, Yale University, 309 Edwards St., Box 208369, New Haven, CT
06520-8369 (email: kelly.brownell@yale.edu).
The Milbank Quarterly, Vol. 87, No. 1, 2009 (pp. 259–294)
c 2009 Milbank Memorial Fund. Published by Wiley Periodicals Inc.
259260 K.D. Brownell and K.E. Warner
the world cannot afford a repeat of the tobacco history, in which industry talks
about the moral high ground but does not occupy it.
Keywords: Food, obesity, tobacco, industry, ethics, politics, public policy.
I n December 1953, the CEOs of the major tobacco
companies met secretly in New York City. Their purpose was to
counter the damage from studies linking smoking to lung cancer. A
year earlier Reader’s Digest—then the public’s leading source of medical
information—had printed an article entitled “Cancer by the Carton”
(Norr 1952). After it appeared, cigarette sales plummeted for two years,
the first such decline of the century except during the Great Depression.
Working closely with John Hill, the founder of the public relations
giant Hill & Knowlton, the industry created “A Frank Statement to
Cigarette Smokers” and paid to have it published in 448 newspapers
on January 4, 1954. To give the industry a human face, the statement
included the signatures of the nation’s top tobacco executives and as-
sured Americans that “we accept an interest in people’s health as a basic
responsibility, paramount to every other consideration in our business.”
Furthermore, they promised that “we always have and always will coop-
erate closely with those whose task it is to safeguard the public’s health”
(Tobacco Industry Research Committee 1954).
The “Frank Statement” was a charade, the first step in a concerted,
half-century-long campaign to mislead Americans about the catastrophic
effects of smoking and to avoid public policy that might damage sales.
Unearthed later, industry documents showed the repeated duplicity of
its executives. Everything was at stake. The industry wanted desperately
to prevent, or at least delay, shifts in public opinion that would permit
a barrage of legislative, regulatory, and legal actions that would erode
sales and profits.
Today another industry is under attack for marketing products per-
ceived by some to damage health, and it also faces legislative, regulatory,
and legal threats that could fundamentally alter how it does business.
Schools are banning soft drinks and snack foods; legislation requiring
calorie labels on restaurant menus has been passed at state and local
levels and is being considered nationally; restrictions in food marketing
practices have been proposed around the world; and even radical mea-
sures such as taxing snack foods are part of the national debate. SuchThe Perils of Ignoring History 261 actions invite comparison of the food and tobacco industries, exempli- fied by a Fortune magazine cover story in 2003 entitled “Is Fat the Next Tobacco?” The cover depicted a French fry lying in an ash tray as if it were a cigarette. The article did what is now common—debate the par- allels between tobacco and food in the context of culpability for health damage and ask whether Big Food should be sued for the same reasons that Big Tobacco was. There are, of course, differences between food and tobacco as sub- stances. The most obvious is that humans must eat to maintain health and life, whereas the unnecessary activity of smoking is, in the words of former Secretary of Health, Education and Welfare Joseph Califano, “slow-motion suicide.” Moreover, selling tobacco to children is illegal, but there currently are no restrictions on food sales. Tobacco has a well- chronicled addictive process, whereas research on food and addiction is just now maturing. And although the fight against tobacco coalesced around a single product made by a few companies, food and its industries are far more complex. The more important issue is whether tobacco history is instructive in addressing the problems created by unhealthy diets. A half cen- tury of tobacco industry deception has had tragic consequences: Since the “Frank Statement,” approximately 16 million Americans have died from smoking, and millions more have suffered from debilitating dis- eases ranging from emphysema to heart disease. Had the industry come clean in 1954—matching deeds with promises—many of these deaths would almost certainly have been prevented. No one knows how many. Perhaps 3 million. Maybe 5 million. Maybe 7 million—just in the United States. An honest approach by industry might have saved more lives than any public health measure taken during the past fifty years. Furthermore, if industry had made good faith efforts globally, rather than exploit and addict the developing world, the benefits could have been stunning. Food, physical inactivity, and obesity may be in the same league. An astonishing two-thirds of the U.S. adult population is overweight or obese (Ogden et al. 2007). As with smoking, social justice issues are prominent, given that obesity rates are highest in the poorest segments of the population (Kumanyika 2006). But weight issues are hardly unique to the United States. The World Health Organization has declared obesity a global epidemic, now surpassing hunger as the chief nutrition problem, even in some developing countries (WHO 2004).
262 K.D. Brownell and K.E. Warner Obesity rates are especially troubling in children, rising at three times the rate of increase in adults (Ogden, Carroll, and Flegal 2008). Indeed, the term adult onset diabetes has now been scrapped and replaced with Type 2 diabetes because children as young as eight are developing the disease. Canadian researchers conducted a fifteen-year follow-up of children diagnosed with Type 2 diabetes and found an alarming rate in young adults of blindness, amputation, kidney failure requiring dialysis, pregnancy loss, and death (Dean and Flett 2002). Health experts now are asking whether America’s children will be the first in the nation’s history to live shorter lives than their parents (Olshansky et al. 2005). Such statistics worry people, leading the press, parent groups, school officials, nutrition experts, health care providers, and government leaders to conclude that something must be done. Caught in the crosshairs, the food industry is reacting, sometimes with heavy ammunition. As an example, in response to menu-labeling initiatives, the restaurant industry has sued New York City, used its political might to weaken legislation in California, and successfully encouraged federal legislators to introduce weak national legislation that would preempt states and cities from acting more aggressively. There are striking similarities, and some differences, in the way the food and tobacco industries have responded to public mistrust, damning scientific evidence, and calls for legal and legislative actions. As an important example of the similarities, food companies have issued their own versions of frank statements, stating their concern with the public’s well-being and pledging to make changes to benefit public health. In this article we discuss what can be learned from tobacco and propose what might be done to avoid the repetition of a deadly history. A Crossroads for Food The food industry is on the defensive, hit hard by nutrition groups and public health professionals, the press, parent groups, child advocacy or- ganizations, and state and national legislators sponsoring bills that could have a powerful impact on business. Popular books like Fast Food Nation (Schlosser 2001) and movies like Supersize Me have sensitized the public to industry practices. In turn, the industry has had to react to claims that it seduces children into a lifestyle of unhealthy eating, infiltrates schools, buys loyalty from scientists, and pressures administration officials into
The Perils of Ignoring History 263 accepting weak and ineffective nutrition policies (Brownell and Horgen 2004; Nestle 2002). To the extent that these charges are fair, the analogy with the tobacco experience is inescapable. Seducing children? There is no better example than Joe Camel. Buying the loyalty of scientists? It happened time and again with tobacco. Using pressure to stall or prevent needed policy change? Few industries have been more effective than tobacco (Advocacy Institute 1998). A first step is to understand the industry players. Unlike tobacco, with one major product and a handful of companies producing it, food involves an immense array of products made by thousands of companies worldwide. The industry is diverse and fragmented in some ways, count- ing as its players a local baker making bread for a few stores; a family running a convenience store; an organic farmer; mega companies like Kraft, McDonalds, and Coca-Cola; and even Girl Scouts selling cookies. The same company making fried foods laden with saturated fat might also sell whole-grain cereal. In other ways, the industry is organized and politically powerful. It consists of massive agribusiness companies like Cargill, Archer Daniels Midland, Bunge, and Monsanto; food sellers as large as Kraft (so big as to own Nabisco) and Pepsi-Co (owner of Frito Lay); and restaurant companies as large as McDonald’s and Yum! Brands (owner of Pizza Hut, Taco Bell, KFC, and more). These are represented by lobbyists, lawyers, and trade organizations that in turn represent a type of food (e.g., Snack Food Association, American Beverage Association), a segment of the industry (e.g., National Restaurant Association), a constituent of food (e.g., Sugar Association, Corn Refiners Association), or the entire industry (e.g., Grocery Manufacturers of America). Common to all these players is an arresting logic: to successfully address the obesity epidemic, the nation must consume fewer calories, which means eating less food. Marion Nestle (2002) estimates that the number of daily calories created for the American food supply rose from 3,300 per person in 1970 to 3,800 in the late 1990s, far in excess of what the average person needs to maintain a healthy weight. If consumers’ demand for food were to reflect what they needed to maintain a healthy weight, the market would contract. A shrinking market for all those calories would mean less money—a lot less. Of course there will always be a need for food—people cannot stop eat- ing. But the types and amounts of food people eat must change dramatically
264 K.D. Brownell and K.E. Warner
if there is to be any hope of curbing obesity and other problems associ-
ated with unhealthy eating. The foods most at risk happen to be those
most processed, dense in calories, highest in profit margin, and sold
mainly by the major industry players.
Industry stands at a crossroads where one turn would mean fighting
change, defending practices like targeting children, forestalling policy
changes, and selling as much product as possible no matter the conse-
quences, and the other would require retooling, working with the public
health community, selling far fewer harmful products, and promoting
healthier options with much greater urgency. Adopting the first option
while laying claim to the second was the path taken by the tobacco
industry. Is the food industry different, or is history repeating itself, this
time with another substance?
In the remainder of this article we discuss the similarities to and
differences from the general playbook/script adopted by the tobacco
and food industries. Next we describe four areas in which the two
industries share distinct similarities and make recommendations for
constructive action by the food industry. These areas pertain to public
relations and framing; influencing government and key organizations;
disputing science, planting doubt, and creating conflicts of interest; and
marketing products. Whether, and how much, the industry chooses to
respond in a responsible manner will determine whether, and how much,
formal governmental regulation of industry behavior will be required to
redress challenges to the public’s health posed by industry products and
marketing behaviors.
The Playbook
The tobacco team had a playbook—a master plan and script that directed
the behavior of industry executives, lobbyists, lawyers, scientists, and
government officials friendly to the industry. In A Question of Intent, a
former FDA commissioner, David Kessler (2001, p. xiii), wrote:
Devised in the 1950s and ’60s, the tobacco industry’s strategy was
embodied in a script written by the lawyers. Every tobacco company
executive in the public eye was told to learn the script backwards and
forwards, no deviation was allowed. The basic premise was simple—
smoking had not been proved to cause cancer. Not proven, not proven,The Perils of Ignoring History 265
not proven—this would be stated insistently and repeatedly. Inject
a thin wedge of doubt, create controversy, never deviate from the
prepared line. It was a simple plan and it worked.
The food industry appears to have a strategy as well, repeatedly carried
to the public by spokespersons from food companies, trade associations,
and their political allies. As noted by Brownell and Horgen (2004) and
Nestle (2002) regarding the food industry specifically and by Mooney
(2006) and Michaels (2008) about industries in general, its main features
are the following:
Focus on personal responsibility as the cause of the nation’s un-
healthy diet.
Raise fears that government action usurps personal freedom.
Vilify critics with totalitarian language, characterizing them as
the food police, leaders of a nanny state, and even “food fascists,”
and accuse them of desiring to strip people of their civil liberties.
Criticize studies that hurt industry as “junk science.”
Emphasize physical activity over diet.
State there are no good or bad foods; hence no food or food type
(soft drinks, fast foods, etc.) should be targeted for change.
Plant doubt when concerns are raised about the industry.
These points play well in America—personal responsibility and free-
dom are central values—but they obscure the reality that some of the
most significant health advances have been made by population-based
public health approaches in which the overall welfare of the citizenry
trumps certain individual or industry freedoms. Can one reasonably de-
fend half a million deaths per year from cigarettes by provoking fears
that freedom and choice are threatened by actions that might adversely
affect the industry? In addition, disputing science has been a key strat-
egy of many industries, including tobacco (Advocacy Institute 1998;
McGarity and Wagner 2008; Michaels 2008; Mooney 2006). Begin-
ning with denials that smoking causes lung cancer and progressing to
attacks on studies of secondhand smoke, the industry instilled doubt.
Likewise, groups and scientists funded by the food industry have dis-
puted whether the prevalence figures for obesity are correct, whether
obesity causes disease, and whether foods like soft drinks cause harm
(e.g., Forshee, Anderson, and Story 2008; Grocery Manufacturers of
America 2003).266 K.D. Brownell and K.E. Warner Public Relations and Framing A great deal of influence rests in the hands of parties who control the framing of a health issue. That is, a problem framed as a matter of per- sonal irresponsibility will be addressed differently from one for which other factors, such as corporate misbehavior, environmental toxins, or infectious agents, are responsible. The tobacco industry devoted consid- erable resources to public relations as its primary weapon to influence public opinion and neutralize calls for government intervention. The food industry, its trade associations, and its political front groups have been similarly aggressive in attempting to shape public and legis- lator opinion. At the heart of this strategy is a script built on values of personal responsibility. The Personal Responsibility Script At the 1996 shareholders’ meeting of cigarette and food manufacturer RJR Nabisco, a woman in the audience asked company chairman Charles Harper whether he would want people smoking around his children and grandchildren. Mr. Harper responded, “If the children don’t like to be in a smoky room . . . they’ll leave.” When the woman responded, “An infant cannot leave a room,” Mr. Harper answered, “At some point they learn to crawl, okay? And then they begin to walk” (RJR Nabisco 1996). Personal responsibility has been invoked to shield the food indus- try from criticism, legislation, and litigation. Legislation sponsored by Congressman Ric Keller (R-FL) in 2004 to ban lawsuits claiming health damages against fast-food restaurants is typical in emphasizing personal behavior: “We’ve got to get back to those old-fashioned principles of personal responsibility, of common sense, and get away from this new culture where everybody plays the victim and blames other people for their problems” (CNN 2004). When asked about the role of restaurants in contributing to the obesity problem, Steven Anderson, president of the National Restaurant Association stated, “Just because we have elec- tricity doesn’t mean you have to electrocute yourself” (Holguin 2002). These assertions illustrate the execution of an organized corporate strategy that shifts responsibility from the parties who make and market products to those who use them (Hacker 2006). A variety of corollary messages are also typical of industry framing, namely, that companies
The Perils of Ignoring History 267 offer choices and pleasure, emphasize moderation, and do not encourage consumers to overuse their products. Industry Self-Regulation as a Defense against Government Action Industries under threat often claim that self-regulation is sufficient and that they deserve the public’s and government’s trust. Then they launch highly publicized pledges for change. Beginning with the “Frank State- ment” made by tobacco companies in 1954 in which companies pledged, among other things, to “cooperate closely with those whose task it is to safeguard the public health,” the industry did its best to fight calls for strict regulation. A modern-day version is the Philip Morris televi- sion campaign focused on preventing youth from smoking. An outside evaluation found that it did no such thing and in fact might affect chil- dren in ways that would make them more likely to smoke (Sebrie and Glantz 2007; Wakefield et al. 2006). Nonindustry antismoking efforts, in comparison, have been successful with both youth and adult smokers (Hyland et al. 2006; Warner 2006). The food industry is in full-scale pursuit of self-regulatory author- ity (Sharma, Teret, and Brownell 2008). The American Beverage As- sociation, in association with the Alliance for a Healthier Generation (2006), announced that it would reduce sales of traditional carbonated soft drinks in schools. Left untouched was an array of beverages whose sales are increasing (e.g., sports drinks), compared with the traditional carbonated beverages whose sales are declining. Another example is the announcement by a coalition of major food companies and the Council of Better Business Bureaus (2007) that their child-marketing practices would change. The impact of these pledges on children’s dietary practices has not been established objectively, but to the extent the tobacco experience applies, there is reason to be on high alert. The child market for the food companies is enormous. American children, counting only those aged five to fourteen, spend $20 billion annually and influence the spending of $200 billion to $500 billion more. Some ad agencies specialize in children’s television marketing and others in product placements in children’s media, handbooks and conferences on child marketing, and prizes for the best marketing campaigns.
268 K.D. Brownell and K.E. Warner In a book on industry self-regulation, Cashore, Auld, and Newsom (2004) note cases in which industry self-regulation has had beneficial effects, typically when an endangered resource is at stake and govern- ment inaction is a threat because rogue players threaten the industry’s survival. Two examples are marine fisheries (Marine Stewardship Coun- cil) and forests (Forest Stewardship Council). When industries are under public relations threats and they worry that the government will be too active, self-regulation is imposed in a different context. Cashore and col- leagues underscore the importance of objective evaluation, not funded or conducted by industry, to establish the impact of pledges. Corporate Social Responsibility Businesses often invest in their communities because it is considered good public relations and is used to burnish the company image. Con- tributing to the community thus can be especially important to com- panies battling tarnished reputations. Corporate social responsibility investments can also pay dividends in buying loyalty, or at least sti- fling opposition, from groups that might otherwise oppose a company’s business practices. For decades, the tobacco industry used perceptions of social responsi- bility to great effect. Contributions to minority and women’s organiza- tions offered implicit encouragement of leaders to target concerns other than smoking. Leaders of African American communities faced a very real conflict: either to help the community by accepting money or to speak out about the disproportionate toll of tobacco on the health of minority populations. Women’s groups, heavily supported by Big To- bacco and buoyed by support for events like the Virginia Slims Tennis Tour, were silent on the rapidly escalating epidemic of lung cancer in women, focusing instead on breast cancer and other problems (Advocacy Institute 1998). In addition to women’s tennis, the tobacco companies have supported dance troupes, museums, and orchestras. Hard-pressed to fund their en- deavors, members of the nation’s cultural elite become vulnerable to the seduction of tobacco money and show their appreciation in statements of support for their benefactors’ good deeds. In 2000, Philip Morris spent $115 million on worthy social causes, including, in addition to the arts, supplying flood victims with clean water and sheltering women
The Perils of Ignoring History 269 who were victims of abuse. The company spent $150 million on a na- tional TV advertising campaign touting its beneficence. It is noteworthy that such “corporate social responsibility” comes cheap. Philip Morris’s spending on good deeds that year constituted one-half of 1 percent of the company’s $23 billion in domestic tobacco revenues (Warner 2002). The food industry also does its share of charitable work and has developed inroads in key social institutions such as hospitals and schools. Ronald McDonald houses are one example. Fast-food restaurants also can be found in the lobbies of many of the nation’s leading hospitals (Cram et al. 2007; Sahud et al. 2006), including McDonald’s franchises in the lobbies of the Cleveland Clinic and the Children’s Hospital of Philadelphia. One study found that fifty-nine of two hundred hospitals with pediatric residencies had fast-food restaurants and that families who made outpatient pediatric visits were four times more likely to eat fast food (at any time of the day) if they visited a hospital with a fast-food restaurant (Sahud et al. 2006). Likewise, schools remain a branding and sales opportunity for the beverage industry at the same time it pledges to protect children (e.g., American Beverage Association 2009). Table 1 identifies some of the measures that the industry could take to rewrite its personal responsibility script and to make the food industry’s behavior truly more socially responsible. Section A of the table lists those measures pertinent to public relations and framing, discussed earlier. Influencing Government and Key Organizations The Influence of Government Decades ago, Big Tobacco adopted a political strategy quite similar to that now employed by the food industry, with tobacco industry spokes- people, paid scientists, and consultants attempting to influence many key decision-making bodies. Little appreciated today is that the govern- ment gave the tobacco industry veto power over the membership of the advisory committee that eventually produced the first surgeon general’s report on smoking and health, published in 1964 (Public Health Service 1964). The tobacco industry’s insider roles have had a profound impact on public policy. As the former FDA commissioner David Kessler explained:
TABLE 1
270
Positions and Activities Common to Tobacco and Food Industries and Recommended Actions for the Food Industry
A: Public Relations and Framing
Current and Past Industry Positions/Actions Recommended Food Industry Actions
Issue public statements of concern about the health of their Do not use corporate giving to neutralize opposition of groups
customers. that may otherwise challenge industry practices.
Launch strong public relations efforts arguing that Sell only healthful products and do not engage in branding
Companies do not promote abuse of their products. (e.g., scoreboards, vending machines) in places such as
Companies simply provide choice. schools and hospitals associated with the health and
The industry promotes moderation. well-being of children.
Personal irresponsibility is at the root of health problems. Use a science-based approach to establish responsibility
Holding companies responsible is unjust finger-pointing.
(e.g., corporate vs. individual) for issues such as obesity and
Government action usurps freedom and choice. do not engage in unwarranted shifting of risk to individuals.
Fund civic activities as signs of social corporate responsibility.
B: Influencing Government and Key Organizations
Current and Past Industry Positions/Actions Recommended Food Industry Actions
Exert strong political influence at federal and state levels by Work with public health leaders to seek ground where
Making large campaign contributions.
profitability and public health coincide, or at least where
Hiring major lobbying firms to block state and local actions.
public health is not harmed, and exert political influence in
this territory (e.g., government programs or incentives for
healthier food formulations, subsidy policies that
K.D. Brownell and K.E. Warner
encourage healthier eating).Participate in a “revolving door” between industry and Do not pressure governments from other countries or
government in key agencies such as USDA and DHHS. international bodies such as the WHO, the Pan American
Argue that industry self-regulation is sufficient. Health Organization, and the Food and Agriculture
Resist regulation initially but when local and state actions Organization to support policies that threaten public
turn against industry, urge weak federal or state action health.
that preempts strong measures at lower levels. Support legislation and regulation that serve the public’s
Pressure U.S. government officials to undermine global actions health, and do not use legislative preemption as a means for
(e.g., activities of the WHO). weakening or preventing actions that states or local
Fund front groups with consumer-oriented names. communities may wish to take.
Fund professional organizations. Cease funding front groups with consumer-oriented names. If
lobbying for an industry-supportive position, do so
The Perils of Ignoring History
honestly, taking ownership of the position.
C: Disputing Science, Planting Doubt, Creating Conflicts of Interest
Current and Past Industry Positions/Actions Recommended Food Industry Actions
Dispute links between product use and ill health. Do not identify for any public relations or legal purposes the
Characterize unfavorable studies as “junk science.” names or institutions of nonindustry scientists engaged as
Vilify and attack the messengers of bad news (e.g., scientists, advisers or supported by industry to conduct research.
advocacy groups). Fully and publicly disclose the names and amounts of money
Use legal resources to challenge scientific assertions in court. paid to nonindustry scientists who serve as advisers,
Fund science as a sign of goodwill and a means of generating data consultants, speakers, etc., and make similar disclosures
supporting industry positions. about research funding.
Pay leaders in science and health fields as advisers, consultants, Develop a means for meeting industry’s legitimate need for
etc. research while keeping the research legitimate:
(Continued)
271272
TABLE 1—Continued
C: Disputing Science, Planting Doubt, Creating Conflicts of Interest
Current and Past Industry Positions/Actions Recommended Food Industry Actions
Provide significant funding to professional organizations. Lobby government to increase science funding, thus
Use advertising dollars as a method of getting recipients, decreasing the need of scientists to rely on industry
e.g., magazines, to “go easy” on the industry. money.
Work with government and scientists to create an
independent nutrition equivalent of the Health Effects
Institute through which science can be funded but not
tied to specific industry players.
Do not fund professional organizations that publish research,
hold meetings, or issue statements that could directly affect
product sales, and fully and publicly disclose the names of
professional organizations that receive funding and the
amounts of such funding.
Respond responsibly to what is likely to become a difficult and
challenging issue—whether food can trigger an addictive
process. Reformulate foods to remove constituents found to
produce effects such as tolerance and withdrawal, and do
not manipulate these to maximize intake, particularly in
children.
K.D. Brownell and K.E. WarnerD: Product Marketing
Current and Past Industry Positions/Actions Recommended Food Industry Actions
Market heavily to youth. Market the benefits of foods in accordance with their actual
Use celebrities to endorse products. health profile, and have experts engaged by nonindustry
The Perils of Ignoring History
Use “stealth” marketing such as product placements organizations such as the Institute of Medicine, Centers for
in movies and television. Disease Control and Prevention, or American Public Health
Promote “safer” versions of products that may not be safer, Association provide objective input on this health profile.
either inherently or due to how consumers use them. Harness industry expertise and resources to market nutritious
products with the aim of decreasing caloric density and
increasing nutrition density.
Do not use celebrities or license characters to promote
unhealthful foods.
Divulge fully and explicitly when marketing is occurring
(product placements, viral campaigns, advergaming, etc.).
273274 K.D. Brownell and K.E. Warner When we launched our investigation of tobacco at the Food and Drug Administration, we had no idea of the power wielded by the tobacco companies. But we soon learned why the tobacco industry was for decades considered untouchable. Tobacco employed some of the most prestigious law firms in the country and commanded the allegiance of a significant section of the Congress. It also had access to the services of widely admired public figures ranging from Prime Minister Margaret Thatcher to Senator Howard Baker. (Kessler 2001, p. xii) Kessler (2001) also noted the influence of the food industry when the FDA addressed issues of food labeling. The beef industry fought the FDA on labeling of fat and promoted a higher number than the FDA’s proposed standard for how many calories a day the average person is expected to consume. Kessler recounted: From the White House, the pressure moved down to the Office of Management and Budget, which had the power to block our regula- tions. As required, we had submitted draft after draft of the final rule to OMB and often had it returned to us with industry-sought changes. More than once, OMB’s wording had been taken almost verbatim from food industry comments we had already carefully considered. (2001, p. 58) In dealing with the obesity issue, one of Tommy Thompson’s early acts as secretary of Health and Human Services (DHHS) in George W. Bush’s administration was to meet with the board of directors of the Grocery Manufacturers of America (GMA), the world’s largest food industry trade association. According to a GMA press release, Thompson applauded the industry for its efforts to deal with obesity, and when asked how to deal with critics who believed that the industry should change its practices, he encouraged the industry to “go on the offensive” (Grocery Manufacturers of America 2002). Thompson figured prominently in another case in which public health and food industry priorities were at odds. In February 2003, the World Health Organization released a draft report outlining a global strategy to address issues of diet and physical activity (WHO 2004). Making recommendations considered tame by many, the report advocated such measures as reducing the intake of sugar and fat and creating a safer nutrition environment for children in schools. Six words in that report, “limit the intake of ‘free’ sugars,” stimulated a remarkable series of
The Perils of Ignoring History 275 events. Free sugars are those added to foods—obvious ones like soft drinks, candy, and desserts but also foods less often thought of as sugar rich, including soups, ketchup, beef stew, and yogurt. The food industry went to work within days of the draft’s release. The sugar industry, through the Sugar Association, enlisted the support of officials high in the U.S. government and led a vigorous attack on both the report and the WHO (Brownell and Nestle 2004). Beginning with letters to the WHO’s director general, the Sugar Association criticized both the science and the process by which the report was prepared and asked that it be stopped, or at the very least, delayed. Not receiving the desired response, the industry quickly raised the stakes when two U.S. senators, Larry Craig and John Breaux, co-chairs of the “U.S. Senate Sweetener Caucus,” implored Thompson to use his “personal interven- tion” in blocking the report. Thompson attempted to deliver. A DHHS assistant secretary sent a twenty-eight-page, single-spaced report to the WHO picking at the science and making the same three points promoted by the industry: per- sonal responsibility should be the emphasis; there should be a stronger focus on physical activity; and there are no good and bad foods. Thomp- son dispatched this assistant to Geneva at the time of a key WHO meeting, pressuring constituent countries to block the report. The Sugar Association simultaneously played its ultimate card. Ex- pressing concern for “the hard working sugar growers and their families,” its president again wrote the WHO, vowing to use “every avenue pos- sible to expose the dubious nature” of the report, “including asking Congressional appropriators to challenge future funding of the U.S.’s $406 million contributions . . . to the WHO.” This is the WHO that deals with AIDS, malnutrition, infectious disease, bioterrorism, and more, threatened because of its stance on sugar. The tobacco history is similar. In its first-ever use of its international treaty-making authority, the WHO proposed, and eventually received, near-universal approval to adopt the Framework Convention on Tobacco Control (FCTC), an international treaty that would, among other things, result in higher cigarette prices, the abolition of most tobacco advertis- ing, and global cooperation in combating cigarette smuggling (WHO 2003). The multiyear effort to develop the FCTC encountered serious opposition from only a handful of countries, with the U.S. delegation leading the charge. The United States’ vocal resistance was noteworthy
276 K.D. Brownell and K.E. Warner in that the convention would have limited impact on this country, which had already achieved much success in tobacco control. Rather, the convention would attack the spread of tobacco in poor and middle- income countries, the principal targets of the industry’s plans for future expansion. Success in the latter endeavor, of course, would affect the fi- nancial well-being of major multinational companies like Altria (parent of Philip Morris). The FCTC experience gave the U.S. administration a black eye and fed perceptions that business interests are more important to the United States than the health of developing countries. The global community adopted the FCTC with such strong unanimity, however, that even the United States voted in favor, but only after the failure of its last-minute efforts to subvert the agreed-upon document. Nearly all the countries that approved the FCTC at the May 2003 World Health Assembly subsequently ratified the convention, making the FCTC one of the most widely and rapidly adopted treaties in history. As of August 2008, 160 countries had ratified the treaty. The United States remains one of the few holdouts. In fact, the Bush administration did not even forward the treaty to the Senate for its consideration. The United States found itself similarly isolated in its attack on the WHO’s diet and nutrition recommendations. Skewered by the interna- tional press and unsupported by food industry giants located outside the country (like Nestle and Unilever), the administration and industry nonetheless maintained their stance. The idea that industry interests should trump public health has been institutionalized in regulatory agencies like the U.S. Department of Agriculture (USDA) by means of a “rotating door” that leads to the reg- ulatory agency’s “capture” by industry (Makkai and Braithwaite 1992). While working to promote healthy eating, the USDA at the same time has as its main objective the promotion of American agriculture (sell- ing more food), so one goal typically prevails over the other when the two conflict. There is a long history of USDA leaders and leaders of other agencies being recruited from food and agriculture industries and then returning to businesses like lobbying firms when their government service ends. Tommy Thompson, a former secretary of DHHS, is now a partner with Akin Gump, a law firm that defended tobacco compa- nies and food companies like Archer Daniels Midland. Daniel Glickman went to the same firm after serving as secretary of the USDA.
The Perils of Ignoring History 277 The Influence of Professional Organizations The food industry enjoys influential positions in surprising places. The American Dietetic Association (ADA), which, in its own words, is de- voted to “improving the nation’s health,” promotes a series of Nutrition Fact Sheets. Industry sources pay $20,000 per fact sheet to the ADA and take part in writing the documents; the ADA then promotes them through its journal and on its website. Some of these fact sheets are “What’s a Mom to Do: Healthy Eating Tips for Families” sponsored by Wendy’s; “Lamb: The Essence of Nutrient Rich Flavor” sponsored by the Tri-Lamb Group; “Cocoa and Chocolate: Sweet News” sponsored by the Hershey Center for Health and Nutrition; “Eggs: A Good Choice for Moms-to-Be” sponsored by the Egg Nutrition Center; “Adult Beverage Consumption: Making Responsible Drinking Choices” in connection with the Distilled Spirits Council; and “The Benefits of Chewing Gum” sponsored by the Wrigley Science Institute. In March 2008, the ADA announced that the Coca-Cola Company had become an “ADA Partner” though its corporate relations sponsor- ship program. In promoting this program, the ADA states that becom- ing an ADA partner “provides partners a national platform via ADA events and programs with prominent access to key influencers, thought leaders and decision makers in the nutrition marketplace” (Ameri- can Dietetic Association 2008). The ADA’s press release also pointed out that “the Coca-Cola Company will share research findings with ADA members in forums such as professional meetings and scientific publications.” The ADA has taken a strong stand that there are no good foods or bad foods, a position that the food industry has then exploited. In its early years, the tobacco industry sounded a similar theme: smoking per se was not bad, only “excess” smoking. Nonetheless, the food industry still has a chance to work with the public health community, professional organizations, and governmental organizations—both national and international—in a manner that pro- motes, not combats, public health. Section B of table 1 offers specific suggestions for appropriate industry actions. (Note that there is some overlap in the four sections. For example, public relations efforts, iden- tified in section A, are intended both to frame issues and to influence governments and key organizations.)
278 K.D. Brownell and K.E. Warner Disputing Science, Planting Doubt, Creating Conflicts of Interest Industry must often contend with research that questions the safety and healthfulness of its products and the impact of practices such as market- ing. There is a long history, in both the tobacco and food industries, of their seeking to influence science. Scientists, Conflicts of Interest, and Industry Front Groups From the early days of research showing the harmful effects of tobacco on health, the industry paid prominent scientists to conduct studies and to act as advisers and consultants with the intent of countering the poten- tially damaging scientific evidence (Cummings, Brown, and O’Connor 2007). This practice continues today (Barnoya and Glantz 2006; Mars and Ling 2008; Schick and Glantz 2007). Michaels (2008), Kessler (2001), and Mooney (2006) all note that this may well be a deliberate strategy to buy loyalty and to instill doubt: to confuse the public, give ammunition to political allies, and stall or prevent government action. A case in point is the tobacco industry’s behavior in undermining the science with respect to secondhand smoke (McGarity and Wagner 2008; Tong and Glantz 2007). Similar concerns have been raised about the food industry (Brownell and Horgen 2004; Nestle 2001, 2002). Many of the major food compa- nies have advisory boards composed of the field’s most visible academics, pay scientists as consultants, and fund research. The question is what industry “buys” with these transactions. It is possible some scientists and professional organizations are not affected, but for others (1) the conduct or interpretation of science becomes biased; (2) scientists or professional organizations issue statements and take positions more fa- vorable to industry; (3) well-placed scientists help industry in key strate- gic roles (e.g., membership on the Dietary Guidelines Committee); and (4) industry uses the funding of research as evidence it is seeking the “truth” about the dangers of its products (McGarity and Wagner 2008). Common sense argues that industry would not spend the money if there were no return, but more important are the data addressing the issue.
The Perils of Ignoring History 279 One example is the research on the connection between the con- sumption of soft drinks and health. A meta-analysis of available re- search showed clear relationships among the consumption of soft drinks, poor nutrition, and negative health outcomes (Vartanian, Schwartz, and Brownell 2007). Within this meta-analysis, which was not funded by industry, those studies with stronger methods were more likely to show these negative outcomes. Furthermore, a comparison of studies funded or not funded by industry showed that the former were more likely to find results favorable to industry. An analysis of studies of the health effects of secondhand smoke produced similar findings (Misakian and Bero 1998). The soft drink industry, through the American Beverage Association (ABA), responded swiftly by supporting a group of researchers to conduct another review of the link between soft drinks and body weight. Two of the authors had conducted multiple industry-funded studies in the past, and one was employed by the ABA when the study was published. This study found that the consumption of soft drinks is not related to negative outcomes (Forshee, Anderson, and Story 2008). There are a few signs that this conflict of interest may improve. “Sunlight” being trained on the issue by the press may shame conflicted scientists and professional organizations into behaving differently. A highly visible case occurred when the press documented that a prominent obesity researcher was paid by the restaurant industry to write a brief in its legal case opposing menu-labeling regulations in New York City (Nichols 2008; Saul 2008; Stark 2008). Improvements also may follow when scientists recognize that the field’s response to conflicts—disclosure—may actually make the situa- tion worse. Cain, Loewenstein, and Moore (2005) found that an audience hearing information from a source who discloses a conflict of interest dis- counts what they hear, but only to a small extent. The source, however, feels emboldened to present his or her views more strongly, ultimately making the conflicted source more, rather than less, credible. This phe- nomenon may apply to organizations as well as to individuals, and as noted earlier, prominent organizations such as the American Dietetic Association and the Obesity Society receive considerable funding from industry. Industry front groups provide another parallel between the industries. The tobacco industry created organizations that appeared at first glance to be grassroots groups seeking to protect smokers’ rights and to fight
280 K.D. Brownell and K.E. Warner off government intrusion (Advocacy Institute 1998; Apollonio and Bero 2007). An industry, of course, has the right to promote its positions, but when money flows through such organizations, their nature and intent are not apparent to the general public. The food industry also funds groups with names that would not necessarily alert the public to the industry connection. The Center for Consumer Freedom is an example. Such front groups attack and instill doubt in published science and the scientists who do research, in concert with the industry script (McGarity and Wagner 2008; Michaels 2008). Addiction Manipulation and Denial The highly addictive nature of nicotine has been long known. Famously, in 1963 a Brown & Williamson executive wrote, “We are, then, in the business of selling nicotine, an addictive drug” (Brown & Williamson 1963). Less than ten years later, a Philip Morris research official wrote, “The cigarette should be conceived not as a product but as a package. The product is nicotine. . . . Think of the cigarette pack as a storage container for a day’s supply of nicotine” (Dunn 1972). Despite revelations such as these, there are questions even today about whether the industry fully admits to the problem (Henningfield, Rose, and Zeller 2006). A striking event occurred in 1994 when the CEOs of every major tobacco company in America stood before Congress and, under oath, denied believing that smoking caused lung cancer and that nicotine was addictive, despite countless studies (some by their own scientists) showing the opposite. Most troubling was the intentional manipulation of nicotine to increase the addictive potential of cigarettes (Hurt and Robertson 1998; Kessler 1994, 2001). Much less research has been done on food and addiction, but the number of studies is growing. Animal studies have shown similarities in the way the brain responds to classic drugs of abuse (e.g., morphine, alcohol, nicotine) and to sugar (Avena, Rada, and Hoebel 2008). Human studies have shown similar findings and have examined how the same reward pathways affect the intake of food and drugs (Adam and Epel 2007; Kalivas and Volkow 2005; Kalra and Kalra 2004; Kelley and Berridge 2002; Volkow and Li 2005; Volkow and Wise 2005; Wang et al. 2004). In addition, scientists who study food and those who study addiction are now interacting (Rudd Center for Food Policy and Obesity
The Perils of Ignoring History 281
2007) and are systematically addressing the issue of whether food can
create an addictive process.
Caffeine is interesting in this context of addiction. Often overlooked
because of perceptions that caffeine produces only mild addiction, several
findings are noteworthy:
1. The pharmacology of caffeine shows clear patterns of dependence,
with signs of tolerance and withdrawal (Juliano and Griffiths
2004; Strain et al. 1994).
2. The range in amount of caffeine within product categories such
as coffees, energy drinks, and carbonated sodas is very wide
(McCusker, Goldberger, and Cone 2003, 2006).
3. Caffeine can sometimes be found in “decaffeinated” products
(McCusker, Goldberger, and Cone 2006).
4. Industry claims to add caffeine because of its flavor-enhancing
properties, but research has shown that individuals cannot de-
tect caffeine in foods (Keast and Riddell 2007). Griffiths and
Vernotica (2000, p. 732), finding that only 8 percent of people
could detect caffeine in cola drinks, concluded that “the high
rates of consumption of caffeinated soft drinks more likely reflect
the mood-altering and physical dependence-producing effects of
caffeine as a central nervous system-active drug than its subtle
effects as a flavoring agent.”
5. Food companies have added caffeine to unlikely foods, includ-
ing potato chips, jelly beans, sunflower seeds, and candy bars
(Brownell, Griffiths, and Gold 2008). We also should point out
that nicotine has been added to food products as well, including
fruit juices, bottled water, and lollipops, although unlike the case
of caffeine, here the presence of nicotine is explicitly promoted
(Warner 2005).
Caffeine may be an important player regarding poor nutrition and
obesity because it is so often coupled with calories (Brownell, Griffiths,
and Gold 2008). Soft drinks, energy drinks, coffee (with cream and
sugar), and other foods to which caffeine is added deliver a great many
calories to their consumers. The possibility of additive or synergistic
addictive effects with caffeine and food substances like sugar thus should
be explored. The degree to which industry intentionally manipulates
caffeine to maximize consumption, especially by children, could emerge
as an issue.282 K.D. Brownell and K.E. Warner It is too early to know how the food industry will react to issues pertaining to food and addiction. Many scientific issues have yet to be addressed, and the press, public, and elected leaders have not yet challenged the industry on this matter. But for such a sensitive issue, and one with potentially important legal implications, one can imagine how threatening even the implication of addiction would be to the industry, as it was with tobacco. Table 1, section C, lists responsible industry practices. Product Marketing and “Safer” Products Another similarity between tobacco and food companies is the intro- duction and heavy marketing of “safer” or “healthier” products. When cigarette sales dropped in the early 1950s owing to health concerns, the industry introduced “safer” cigarettes that gave health-conscious smok- ers an alternative to quitting (Cummings, Brown, and Douglas 2006). Filtered cigarettes, sold with the explicit message that filters removed dangerous substances while preserving flavor, were marketed aggres- sively. Cigarette consumption then resumed its upward trajectory, and within a decade, filtered cigarettes came to dominate the market. Ironi- cally, the filter of the first highly successful brand of filtered cigarettes, Kent, added to the smoking experience yet another dangerous substance: the asbestos in its filter (Slade 1993). Fifteen years later, industry addressed the widespread fear of smoking by introducing low-tar and -nicotine cigarettes. Advertising explicitly conveyed the message that these new “light” cigarettes were safer. An ad for True cigarettes read, “All the fuss about smoking got me thinking I’d either quit or smoke True. I smoke True.” Within a decade this new product dominated the market. Moreover, the cigarette companies enjoyed a windfall because they retained customers while selling them a product that required many of them to smoke even more cigarettes to accumulate their accustomed intake of nicotine. Industry analysts have observed that low-tar and -nicotine cigarettes were designed as public relations devices, not harm reduction products (Pollay and Dewhirst 2001). The industry knew that the cigarettes generated offi- cial machine-measured tar and nicotine yields far lower than they would when smoked by human beings (due to the location of ventilation holes, designed so that they would be blocked when held by fingers, but not
The Perils of Ignoring History 283
blocked when held at their very tip by a testing machine). Yet even today,
smokers of “lights” believe, erroneously, that their risk of death from
smoking is substantially below that of smokers of “full-flavor” cigarettes
(Shiffman et al. 2001; Weinstein 2001). Smokers of low-tar cigarettes,
who frequently pull harder on their cigarettes, are now developing can-
cers farther down in the lung than was the case with traditional cigarettes
(Brooks et al. 2005). These “safer” products have had disastrous results
for public health (Warner 2005).
For many years the food industry has marketed both products with
smaller amounts of those ingredients thought to cause harm (e.g., sugar,
fat, salt, trans fats) and products supplemented or fortified with ingredi-
ents purported to improve health (e.g., vitamins and minerals, oat bran,
whole grains). Fueled in part by lax government regulation of marketing
and health claims, there has been an explosion of such products in recent
years. Some examples:
Removing trans fats is a positive development, but the degree of
health benefit depends on what is used as a replacement (saturated
fats are more damaging replacements than polyunsaturated or
monounsaturated fats).
A KFC ad campaign depicted an African American family in which
the father was told by the mother that “KFC has 0 grams of trans
fat now.” The father, in the presence of children, shouts, “Yeah
baby! Whoooo!!” and then begins eating the fried chicken with
abandon. Does such an ad imply it is now fine to eat fried chicken
and potentially increase consumption in ways that contribute to
obesity (there is no calorie advantage of switching one fat for
another)?
General Mills has an aggressive marketing and packaging cam-
paign to tout the fact that its cereals are made with whole grains,
including high-sugar products like Lucky Charms and Cinna-
mon Toast Crunch. Whether consumers, responding to the Gen-
eral Mills campaign, would overestimate the benefit of the grain
change and increase their consumption of such cereals is not
known.
At the center of this issue is whether industry can be trusted to make
changes that benefit the public good and can be responsible with the
accompanying marketing. The tobacco history is clear and is captured in
a quotation from Cummings, Brown, and O’Connor (2007, p. 1070): “IfYou can also read
